The numbers, working together
Premium and deductible are only half the picture. A copay is a flat fee for a service, such as $30 for an office visit. Coinsurance is your percentage share of a bill after the deductible is met, commonly twenty percent. The out-of-pocket maximum is the most you can be made to pay for covered in-network care in a plan year. On a plan with a $2,000 deductible, twenty percent coinsurance and a $6,000 out-of-pocket maximum, a $12,000 surgery costs you the first $2,000 plus twenty percent of the remaining $10,000, for a total of $4,000. To compare plans, add a year of premiums to the out-of-pocket maximum, which gives your worst case.
Networks decide what you pay
An HMO generally covers only in-network providers and asks you to get referrals through a primary care doctor. A PPO lets you see specialists directly and pays part of out-of-network care, at a higher premium. An EPO sits between them, with no referrals and no out-of-network coverage. Before you choose, search the plan's directory for the doctors and hospital you already use, then confirm with the doctor's office, because directories are often outdated.
Where coverage comes from
- An employer plan is usually cheapest, because the employer pays a large share of the premium.
- A parent's plan can cover you until you turn twenty-six, even if you are married or living elsewhere.
- The federal marketplace at healthcare.gov, or your state's own exchange, sells individual plans with income-based subsidies.
- Medicaid covers people with low incomes, and in most states that includes adults without children.
- COBRA lets you keep a former employer's plan, usually for up to eighteen months, but you pay the entire premium yourself.
Open enrollment comes once a year, typically in the fall. Outside it, a qualifying life event, such as losing other coverage, marrying or having a child, opens a window of sixty days on the marketplace and usually thirty on an employer plan.
Using the plan well
Preventive care, including an annual physical, standard vaccines and many screenings, is covered at no charge in-network. Use urgent care for anything short of life-threatening, since an emergency room costs far more. After any care you will receive an explanation of benefits, which is not a bill. Wait for the provider's bill, check that the two agree, and ask for an itemized bill whenever a charge looks wrong.
Tip If you are turning twenty-six or leaving a job, mark the date your coverage ends and start shopping a month ahead, so that no gap opens.
